Clinical Perspective of Valvular Heart Disease Flashcards
1
Q
Posteromedial Papillary Muscle Blood Supply
A
- Posterior descending branch of a dominant right coronary artery
- Assoc. w/ inferior wall infarctions
- Rupture of the posteromedial papillary muscle is most commonly seen in about 75% of cases
2
Q
Anterolateral Papillary muscle Blood Supply
A
- Obtuse marginal branchs of the left circumflex; and from diagonal branches of the left anterior descending
- Rupture of the anterolateral muscle is less common; occuring in 25% of cases, as it has a dual blood supply
3
Q
Tricuspid Regurgitation
A
Tricuspid valve insufficiency (regurgitation) may be due to:
- Leaflet abnormalities, which may be secondary to endocarditis or rheumatic heart disease (assoc. in combination w/ tricuspid stenosis)
- Ebstein’s anomaly- the most common congenital form of tricuspid regurgitation
- Ischemia of the papillary muscles
- RV dilation, which may be due to left heart failure or pulmonary hypertension
- Carcinoid
4
Q
Ebstein anomaly
A
- Congenital malformation in which there is apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle (there is variable degree of malformation and displacement of the anterior leaflet)
5
Q
Tricuspid Regurgitation Signs and Symptoms
A
- Present w/ right sided heart failure
- Symptoms dependent upon whether the condition is secondary to left ventricular (LV) dysfunction, which would then be assoc. w/ dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, accompanying ascites and peripheral edema as common presenting complaints
- S3 gallop may be present
- Jugular venous distension w/ a prominent V wave: when present, a pansystolic murmur is heart along the lower left sternal border w/ inspiratory accentuation
- Pulmonary rales if the tricuspid regurg is assoc. w/ LV dysfunction or mitral stenosis
- Ascites
- Peripheral edema
- Cachexia and jaundice
- Atrial fibrillation may be assoc. w/ progressing TR
- With inspiration the severity of TR increases, due to inspiratory-induced widening of the RV, which results in enlargement of the tricuspid valve annulus and an increase in the effective regurgitant orifice area
6
Q
Tricuspid Regurgitation Common Causes
A
- History of IV drug use
- Rheumatic fever
- Febrile episodes
- Endocarditis Ebstein anomaly
- Carcinoid
- Papillary muscle dysfunction
- Trauma
- Connective-tissue diseases
- Medictions (fenfluramine)
- Dilation of the RV cavity
- Prolapse
7
Q
Mitral Regurgitation Common Causes
A
- MVP syndrome
- Rheumatic heart disease
- CAD
- Infective endocarditis
- Drugs
- Collagen vascular disease
- Dilated annulus from dilation of the left ventricle
- Ruptured chordae tendineae
- Ruptured papillary muscle
8
Q
Mitral Regurgitation Signs and Symptoms
A
- Almost always severely symptomatic
- Physical exam of the precordium may be misleading, b/c a normal-sized left ventricl does not produce a hyperdynamic apical impulse
- Systolic murmur of MR may not be holosystolic and may even be absent
- Transthoracic echo may help diagnosis, however may underestimate lesion severity; transesophaegeal can more accurately assess
- RED FLAG: If there is hyperdynamic systolic function of the left ventricle on a transthoracic echo in a pt. w/ acute heart failure, the suspicion of severe MR should be raised
9
Q
Mitral Stenosis Common Causes
A
- Rheumatic fever (most common cause)
- Congenital
- Malignant carcinoid disease
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Mucopolysaccharidoses of the Hunter-Hurler phenotype
- Fabry disease
- Whipple disease
- Methysergide therapy
- The assoc. of atrial septal defect w/ rheumatic mitral stenosis is called Lutembacher syndrome
10
Q
Mitral Stenosis Signs and Symptoms
A
- Multiple inflammatory foci (Aschoff bodies, perivascular mononuclear infiltrate) in the endocardium and myocardium; resulte of rheumatic carditis
- As it progresses leads to transudation of fluid into the lung interstitium and dyspnea at rest or w/ minimal exertion
- Hemoptysis
- 2/3 of all pts. w/ rheumaitc mitral stenosis are female
- Onset of symptoms usually occurs b/w the 3rd and 4th decade of life
- Hoarseness can develop with persistent cough
EXAM
- Diastolic murmur is of low pitch, rumbling in character and best heard at the apex w/ the pt. in left lateral position
- Commences after the opening snap of the mitral valve and murmur duration correlates w/ severity of stenosis
- Murmur is accentuated by exercise, whereas it decreases w/ rest and Valsalva maneuver
11
Q
Aortic Stenosis Common Causes
A
- Congenital (unicuspid or bicuspid valve)
- Calcific (due to degenerative changes)
- Rheumatic
12
Q
Aortic Stenosis Signs and Symptoms
A
- Usually develop gradually; can have latent period of 10-20years
- Triad of symptoms
*syncope
*angina
*dyspnea
EXAM
- Pulsus parvus et tardus pulse; delayed carotid arterial pulse w/ plateau peak, decreased amplitude, and gradual downslope. This may not easily be appreciated in elderly individuals. Look for a lag b/w the apical impulse and the carotid impulse
- The aortic component of the second heart sound is often diminished or abset
- Prominent S4
- Crescendo-decrescendo systolic murmur harsh, high-pitched sound that is best heard at the second intercostal space of the right upper sternal border and radiates to the carotids
- Gallavardin phenomenon
- Murmur is augmented by squatting
- Murmur intensity is reduced by valsalva
13
Q
Degenerative Calcific Aoritc Stenosis Common Causes
A
- Due to progressive calcification of the leaflets
- Most common cause of aortic stenosis leading to aortic valve replacement
- Calcification may also involve the mitral annulus or extend into the conduction system, resulting heart blocks
RISK FACTORS
- Hypercholesterolemia
- Diabetes mellitus
- Smoking
14
Q
Rheumatic Aoritc Stenosis Common Causes
A
- Results from pregressive fibrosis of the valve leaflets leading to commissural fusion and often retraction of the leaflet edges. Calcification may also occur
15
Q
Aortic Insufficiency (Regurgitation) Common Causes
A
- Bacterial endocarditis over rheumatic heart disease
- In developed countrisl is most commonly caused by dilatation of the ascending aorta, from aortic root disease or even aortoannular ectasia
ACUTE
- Rheumatic
- Infective endocarditis
- Ruptured sinus of valsalva
- Trauma
- Aortic dissection
CHRONIC
- Infective endocarditis
- Hypertension
- Rheumatic
- Syphilis
- Aortitis (Takayasu disease)
- Marfan
- Bicuspid aortic valve defect
- Ankylosing spondylitis
- Reiter syndrom
- Rheumatoid arthritis
- Systemic lupus erythematosus
